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A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.
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A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan?
- A. Place the client in seclusion when he exhibits signs of anxiety.
- B. Encourage the client to spend time in the dayroom.
- C. Withdraw the client's TV privileges if he does not attend group therapy.
- D. Encourage the client to take frequent rest periods.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to take frequent rest periods. During mania, clients with bipolar disorder may experience heightened energy levels and decreased need for sleep. Encouraging rest periods can help regulate energy levels and promote better sleep patterns, which are crucial in managing manic episodes. Placing the client in seclusion when anxious (choice A) can increase feelings of isolation and worsen symptoms. Encouraging the client to spend time in the dayroom (choice B) may not address the need for rest. Withdrawing TV privileges (choice C) may not directly address the client's manic symptoms.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps manage withdrawal symptoms in clients with opioid use disorder. It reduces cravings and prevents withdrawal without causing euphoria. Disulfiram (B) is for alcohol use disorder, Naloxone (C) is an opioid antagonist used for opioid overdose reversal, and Bupropion (D) is an antidepressant and smoking cessation aid.
A nurse in a mental health clinic receives a request from a client who is undergoing psychotherapy to obtain a copy of the therapist's notes. Which of the following responses should the nurse make?
- A. "Are you not happy with your treatment?"
- B. "Why are you interested in seeing your therapist's notes?"
- C. "We can provide a copy of your records, but the therapist's notes are not included."
- D. "I don't think you will benefit from reviewing your therapist's notes right now."
Correct Answer: C
Rationale: The correct response is C: "We can provide a copy of your records, but the therapist's notes are not included." This response aligns with ethical guidelines and laws that protect the confidentiality of therapist-client communication. Providing therapist's notes without proper authorization may breach confidentiality and harm the therapeutic relationship. Other choices lack professionalism and may undermine the client's trust. Option A implies judgment and defensiveness. Option B can be seen as intrusive and may put the client on the defensive. Option D dismisses the client's request and may discourage open communication. Overall, option C respects confidentiality, maintains boundaries, and upholds the client's right to privacy.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps prevent withdrawal symptoms in clients with opioid use disorder by reducing cravings and preventing withdrawal symptoms without causing euphoria. Disulfiram (B) is used for alcohol use disorder, Naloxone (C) is an opioid antagonist used for opioid overdose reversal, and Bupropion (D) is an antidepressant that is not indicated for opioid withdrawal. By choosing Methadone, the nurse is providing appropriate pharmacological support for the client's opioid use disorder.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander. Placing locks at the tops of doors can prevent the client from easily opening them and wandering off, which is a common behavior in Alzheimer's patients.
A: Replacing carpet with hardwood floors may not directly address the safety concern of wandering.
B: Encouraging physical activity prior to bedtime may help with sleep but does not address the safety issue of wandering.
C: Wearing clothing with zippers instead of buttons may be easier for the client to manage, but it does not address the safety concern of wandering.
Summary: The key consideration in caring for a client with Alzheimer's disease is ensuring their safety, particularly in preventing wandering, which is why placing locks at the tops of exterior doors is the most appropriate action.